Dispelling nutrition myths, ranting, and occasionally, raving

A little while ago I wrote about the importance of representation and how the health care industry is failing at it. Of course, it’s not quite as simple as saying “we’re going to use more diverse images in our marketing and materials”. Most organizations don’t take their own photos. Instead, most use stock photography sites from which staff select images. It’s not just health care that has a problem, it’s all media, and it’s the sites from which we source our images.

So many of the images I come across on the stock photo site we use at work are problematic. I’m not going to name the site because it really doesn’t matter which one it is, they’re all the same. Search the word “healthy” and you’ll likely come up with a lot of smiling, slim, glowing, youthful white people outdoors wearing athletic clothing or eating salad. Of course there might be one older person, a black person, and a “normal” (i.e. not model thin) person in the mix but these are the exceptions that prove the rule. Fitness returns more of the same, minus the salad shots. On the other hand, when you search “fat” you come back with a bunch of headless torsos clutching their bellies, larger people drooling over fries, large people looking miserable, and a few “good” fat people engaging in physical activity – again, the exceptions that prove the rule. Then there’s the images of “healthy choices” in which the ubiquitous glowing youthful white woman is weighing a doughnut in one hand and an apple in the other as if this is all that healthy eating is about. Or how about the images of large women kicking “junk food” solidly away? How virtuous. Or the woman literally taking a pair of scissors to her stomach? Horrifying.

All these images do is serve to reinforce the popular beliefs that we hold around body size, health, and personal responsibility. To reinforce the stigma against larger bodies and the false assumption that smaller bodies are always healthy bodies and the result of healthy personal choices. It takes a lot of effort and consideration for people to choose images from these stock photo sites that don’t contribute to stereotypes. It’s worth that extra effort though to show that all bodies are good bodies and that your organization is for everyone, not just people who look a certain way.

The above inane tweet last week prompted me to post a couple of tweets in which I screamed into the void about a) people not following dietary guidelines anyway and b) weight not being indicative of health. Which then lead to me posting the following poll:

Obviously, this is a completely unscientific poll but it does show that the majority (83%) of RDs who responded do not generally follow the dietary guidelines for their respective counties. This could be for any number of reasons. Most didn’t respond with a reason. Those who did said that they weren’t big on fruit of dairy or the carbs (that’s the grains food group) are too high. Personally, I suspect that some days I’m low in vegetable and fruit consumption or milk and alternatives. Other days I’m definitely over. And if I’m being completely honest, I have something from that “other” food group (aka sometimes foods) on the daily.

The truth is, the Food Guide is just a guide. It’s not a bible. It’s intended to provide people with all of the nutrients and energy they need to be healthy and active but everybody is different. We all have different needs and preferences. I know that people really like to rag on dietitians and say that all we do is preach the food guide but I’m here to rain on that parade. Dietitians are people too and we enjoy food for more reasons than just as fuel. We are not robots that run on kale and quinoa. I think that most of us think that the food guide could be improved (and fingers crossed it will be whenever they finally come out with the new version) but we also know that it’s just meant to be a tool.

Food Guides are meant to guide people toward nutritious food choices. They encourage a variety of foods from all of the food groups. The overall message that people should be taking from a food guide is that there are healthy choices in all the food groups and eliminating any one food group may result in deficiencies. Also, that eating only one type of food from each food group (e.g. lettuce as your only veg or bread as your only grain) is not going to provide you with all of the nutrients that you need. However, it’s also important to listen to your own body and nourish it accordingly. If you’re not hungry don’t sweat the fact that you’ve only had 5 servings of vegetables or 4 servings of grains. Conversely, if you’re extra hungry one day, don’t feel like you have to limit yourself to the servings recommended in the Food Guide.

Healthy eating really doesn’t have to be complicated or rigid. In fact, if you think that you’re eating healthily and you’re finding that it is complicated or rigid then you diet (or relationship with food) probably isn’t all that healthy after all.

Someone I follow on twitter recently shared this blog post: The Rise of the Anti-Diet Movement: Is it No Longer P.C. to Want to Lose Weight? by another dietitian, Janet Helm. In the post she mused about dietitians promoting themselves as “non-diet” and what this might say about other dietitians. She agreed with many points made by dietitians, quoted in RD/writer Cara Rosenbloom’s recent excellent piece for the Washington Post about non-diet dietitians, but seemed unwilling to go so far as to embrace the philosophy herself. She ended her post with the following questions: “Can’t we all get along? Can’t intuitive eating and body positivity coexist with losing weight? Why must we line up on two sides? Why the conflict?” I’m going to do my best to respond to these questions.

First, I too have asked that same question: “Can’t we all get along?” at times. Remember craisingate? Personally, I don’t think that as dietitians we have to agree on everything. It’s okay for us to have different perspectives and approaches. Also, in the case of diet vs non-diet, I don’t see it as an issue of getting along. Maybe I’m blissfully unaware, but I haven’t seen any “non-diet” dietitians attacking other dietitians for promoting weight management. I don’t see dietitians referring to themselves as “non-diet” as lining up on an opposing side or creating conflict. Rather, I see this identification as a way for dietitians to let prospective clients know that they do not promote weight loss as a goal. In a profession which so many believe our sole mission is to help people lose weight I think that it’s necessary for RDs who do not promote weight loss diets to make this clear up-front. I don’t believe the intent is to pass judgement on other dietitians who haven’t embraced the same approach, or to create a professional divide. However, I can see how a dietitian who has built a career around weight management counselling might see this new-ish movement as a personal judgement.

My friend Cheryl Strachan, aka “Sweet Spot RD” wrote an excellent blog post last week (while I was mulling over how best to respond to Janet’s post): Why I can’t help you lose weight. This heartfelt post explained why she would no longer work with clients on weight loss. Providing the current evidence on weight loss and health and the struggle she went through to reach this position. Rather than having me regurgitate all of the evidence here, I recommend you take a few minutes to go read it and then come back.

Done? Okay, great. So you’ll note that Cheryl mentions that when she studied nutrition in 2003 it was accepted without question that weight management was a significant part of being a dietitian. I can tell you that it was the same when I went back to uni to study nutrition in 2006. I’m not sure if things have changed since then. I suspect that they haven’t, at least not completely. It takes time for institutions and society to change. As a dietitian who has worked in weight management in the past I too have struggled to fully embrace health at every size. I understand why a fellow dietitian would ask: Can’t intuitive eating and body positivity coexist with losing weight? It’s an incredibly tough question and the answer is nuanced and it may not be the same for everyone.

I do believe that intuitive eating and body positivity can peacefully coexist with weight loss. However, I think that this can only be the case when weight loss is not the ultimate goal. For me, body positivity is appreciating your body as it currently exists and continuing to appreciate it if you gain weight or lose weight. It’s about treating yourself with respect and compassion and providing your body and mind with the nourishment they need. If you are doing these things with the clandestine goal of losing weight then you are doing yourself a disservice. That being said, it’s okay to want to lose weight. We live in a society that has conditioned us from a very young age to believe that being thin is important. It’s unrealistic to except this engrained belief to vanish overnight. It takes time to relearn to listen to your body and to treat it with respect when you’ve been viewing it as the enemy, a captor, keeping the real you the thin you hidden away. So, no, body positivity and weight loss can’t coexist but yes, body positivity and weight loss can coexist.

I think that as time goes on and nutrition programs update their curriculums, as old-school dietitians are more exposed to evidence regarding the harms of weight bias and weight loss diets, and the hold-outs retire, that things will change. After all, as dietitians we are supposed to provide evidence-based best practice and the evidence against weight loss diets is mounting. Eventually there will be no non-diet dietitians because that will be the approach we all take.

Sometimes I think that we would all be so much better off if the Internet collapsed. Or at the very least, social media networks.

I was reading this article: The Death of Civility in the Digital Age that Yoni Freedhoff shared on his blog last week and thinking about how true it is. People are so ready to attack, always looking for a fight, on social media. The interaction of your fingers with your computer or mobile phone sending out words to someone you’ve probably never even met irl is vastly different from having a conversation with someone face-to-face, or even over the phone. It’s so easy to respond hastily and to neglect to consider that your words will be read by a real actual live human.

While I love that I can find the answer to nearly any question immediately on a tiny computer I carry in my purse I find myself more and more often wondering if it’s worth the cost we’re paying. Egregious cellphone bills in Canada aside, I mean what we’re paying in declining humanity and rampant misinformation.

I can find the answer to nearly any question online but anyone can put what they believe to be the answer out there. This means, especially in the world of nutrition, that there can be heaps of misleading, inaccurate, and completely false information that I need to sift through and assess before I come to the correct answer. There is an ever growing mountain of misinformation online and a tide of dietary dogma on social media. It’s ever so tempting to just shut it out but I feel an obligation to stay online to fight it, to try to dilute it with as much truth as I can. Which is hard because there aren’t many hard and fast truths when it comes to a balanced diet, despite what the radical carnivores, vegans, ketoites (I don’t know what they call themselves), LCHF-ists, HCLF-ists, etc etc would have you believe.

I also hate the constant need for self-promotion. I’m reading the novel Radiant Shimmering Light right now and the whole obsession with getting likes on IG, and RTs on Twitter really rings true. There are a few characters in the book who are “lifestyle” bloggers and they present these varnished, edited versions of their lives as currency. They make money through links on their websites and through selling the idea of perfection and self-marketing. The book is kind of poking fun at this world we’ve created but it’s done so in a way that you really feel the anxiety-provoking compulsion of the narrator to check her notifications. It’s nearly impossible for a dietitian, especially one in private practice, to not use social media. There are dietitians who make a living by coaching others on how to optimize their Instagram feeds. Like are you even a dietitian if you’re not posting perfectly styled photos of acai smoothie bowls and kale salads?

Our years of nutrition education and proof of ongoing education are no longer enough. Now we must be savvy social media marketers, chefs, expert food stylists, and photographers. We must be brands in and of ourselves. We must constantly be competing with self-styled nutrition gurus, other dietitians, and ourselves. I know that I’ve probably got my rose-coloured glasses on, but I yearn for a day when I don’t have to see literal meatheads mocking people for eating plants on twitter. When I can be blissfully unaware of the insane dietary advice naturopaths and some chiropractors are doling out to their clients. When I don’t have to see dietitians promoting juice as nutritious. When we can all just stay in our lanes and do the jobs we were trained to do.

Like this:

I feel like there’s one thing missing from a lot of the discussion about the keto diet (and similar extreme diets, really). Everyone talks a lot about whether or not it “works” with proponents on both sides, research supporting both sides, arguing that it does or doesn’t work for weight loss. The problem with this is the assumption that weight loss is the most important feature of a good diet. It’s not. You can lose weight eating lots of things that are not going to provide you with the nutrients you need. Weight loss is not the most important thing for health, despite what the media, the “wellness” industry, society, and even many health care professionals have lead us to believe.

Just because you feel good on a ketogenic diet and are losing weight doesn’t mean that it’s a good idea. As a dietitian, this is something that I really struggle with. It’s our job to support people. We can tell them that keto is a difficult diet to follow, that it may not be advisable, but when it comes down to it, they decide if it’s something they want to pursue or not. And if they do decide to pursue it, we can’t say “well, good luck, I wash my hands of you”. We have to help them undertake it in as healthy a way as possible. Which kind of blows my mind (and makes me glad that I don’t work in a counselling role) because if someone came to us with an eating disorder we wouldn’t support them in that. How can it be ethical for us to support people in following a diet that may cause them harm?

A little history of keto: the ketogenic diet originated as a treatment for epilepsy in children in the 1920s. It was intended to mimic the effects of fasting through the generation of ketones. In recent years this concept has caught on with people desiring to lose weight. After all, if ketones are produced during fasting, then if a specific diet can promote the production of ketones, it may also lead to weight loss. Not illogical. In some children with epilepsy who do not experience a reduction in seizures with medications, the ketogenic diet can be an effective treatment. However, there are potential side-effects.

A few long-term studies (1, 2) have looked at the effects of the ketogenic diet in children and have found such side-effects as: kidney stones, slowed growth, dyslipidemia, and fractures. There are also short-term risks (2, 3, 4) associated with the diet in children with epilepsy including: acidosis, hypoglycemia, gastrointestinal distress (including vomiting, constipation, diarrhoea, and abdominal pain) dehydration, hypoproteinemia, and lethargy. All of these studies have found low long-term adherence among children. There are many reasons for this: some children see improvement in symptoms, even after discontinuing the diet, others find it difficult to adhere to the diet, for some it’s not effective.

Of course, adults who wish to lose weight are not the same as children who have epilepsy. It’s hard to say if slowed growth in children would have a similar counterpart in an adult. However, many of the short-term side effects may be seen in adults, as may some of the other long-term side effects. In addition, there is potential for nutrient deficiencies when following such a restricted diet. Unfortunately, we don’t have research into the long-term effects of a ketogenic diet on adults using it for weight loss. We have some short-term studies that primarily look at it from the standpoint of whether or not it’s an effective weight loss diet. Maybe it’s perfectly safe, but maybe it’s not. Given that the vast majority of people who lose weight on the diet end up regaining it, and often more, is it really worth taking that risk? By following a keto diet you’re basically enrolling yourself in an uncontrolled experiment.

I think it would be interesting to know what the long-term effects of a ketogenic diet for weight loss are in adults. What I’d really like to know though is why we have become so obsessed with being thin that we are willing to adopt disordered eating habits at the expense of other aspects of our health and well-being. Why is it when we talk about a diet “working” we de facto mean weight loss? Why have we come to value weight loss over every other indicator of health? Why can’t we just value ourselves enough to properly nourish our bodies?